Chance for a cure to VA scandal

With San Diego County serving as home for the largest concentration of veterans in the United States, most of us know or are related to a veteran being treated at San Diego VA Hospital. Many of us have worked there. Forty years ago, as a UCSD faculty member, I practiced there. Having then just moved from the University of Pennsylvania, I was amazed at the hospital’s spic-and-span spaciousness and its dedicated staff and was proud to work there.

Walking its halls today, one realizes it is a more crowded and impacted facility. I recently returned to the VA to introduce a new concept in patient care to its staff. PAVE, Physician Advocates for Veterans, offers to pair a veteran directly with a retired volunteer doctor who privately helps her/him to better navigate the often-confusing health care system. We do not treat patients, but rather educate them as to their disease ramifications and treatment options, and prepare them for their doctor appointments. Thus empowered, they can become advocates for themselves and the interaction between their VA health care providers made more efficient.

The supposed secret waiting lists and related deaths at the VA Hospital in Phoenix have all of us worried. I wonder if a PAVE program might have made a difference in what happened there.

The military culture spawns, at an ever-increasing rate, veterans entering civilian life. The Department of Defense goes to great lengths to assure that this transition is as smooth as possible. That same culture also operates with a dictum of dutiful compliance to a higher command. Such obedience, when coupled with youth, PTSD, traumatic brain injury, multiple war wounds and a lack of understanding of complex health issues, puts veterans at a distinct disadvantage in the hierarchical VA health care system.

In a sense, even civilian doctors are perched on a high branch in their interactions with their patients. We all feel dependent during our visits to our white-coated saviors. Who among us has not left a doctor’s office wondering what was said? Some civilians circumvent this problem by informally chatting with a physician they know. Doctors thus contacted give explanations to what we term our “friends and family.” PAVE adopts veterans into a similar relationship.

PAVE does not charge for its services and operates under the aegis of the San Diego County Medical Society Foundation. It began operations in early 2014. Its volunteer physicians, mostly retired, interact directly with their veterans in an educational or coaching role with the goal of empowering them to better understand and utilize their health care options. The San Diego VA provider staff have largely endorsed the PAVE concept. PAVE-prepared patients should improve the efficiency of veteran-provider appointments, which tend to be relatively rare and fast moving under the best of circumstances.

Consider how PAVE might have altered what allegedly happened at the Phoenix VA. The PAVE physician would have learned how long the veteran had been waiting for a medical test. With an understanding of the veteran’s medical condition, our doctor might have alleviated the veteran’s anxiety by explaining the medical condition didn’t warrant the test on an emergent basis. On the other hand, the test might be vital with to the treatment outcome, and we might inform the patient to press on to get the test done as soon as possible.

While it is not our job to second-guess health care provider intentions, it is also possible that the same VA doctor has no idea the test had been delayed.

In practice, most physicians are familiar with a team approach to care and what can go wrong with it. As PAVE’s volunteers are not on the VA payroll, we have no conflict of interest. We can advise a patient to contact the VA Advocate Office. If necessary, and with the patient’s permission, we might also make contact with our veteran’s primary care physician or case manager. As fellow physicians, we might garner their attention in their overburdened environment. No doubt, this helping-one-vet-at-a-time approach has advantages and disadvantages, but we have not been overloaded at this time.

An operational PAVE-like program embedded within the Phoenix VA Hospital might have much sooner turned patient frustration with their rationed services into a corrective administrative action. While our nation and its VA system will now go through years of prolonged rounds of investigations and Congressional hearings, perhaps the PAVE approach to educating and empowering veterans might have allowed them to cure some to the problems in their own hospital before the deaths occurred. With a PAVE physician backing them, veterans can speak with a louder and more informed voice amid the cacophony of “blame the other guy,” Surely that voice will get faster health care for individual vets, as the administrative and legislative dogfight develops above their heads.

Shapiro is a retired physician and an emeritus UCSD professor and former dean of clinical affairs. Along with Dr. Rosemari Johnson, he is co-chair of PAVE.